Features May 2015 Issue

When You Can’t Stomach NSAIDs

If you can’t take the usual route to pain relief, some effective alternatives are worth exploring.

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Nonsteroidal anti-inflammatory drugs can cause gastrointestinal symptoms, such as nausea, upset stomach or, in more severe cases, stomach ulcers.

Nonsteroidal anti-inflammatory drug (NSAID) pain relievers are relied upon for people battling arthritis. Yet, for many NSAIDs simply aren’t an option due to the upset stomach and nausea—or more severe effects including ulcer or gastrointestinal (GI) bleeding—they can cause. If your doctor has recommended you stop using NSAIDs, such as ibuprofen (Advil®, Motrin®) and naproxen (Aleve®, Naprosyn®), you may be wondering where you can turn for relief.

Fortunately, there are several NSAID alternatives to consider. It may take a little investigation as to which one works best in your situation, but options are out there to explore, say Cleveland Clinic experts.

Alternate oral medications

If you have to avoid NSAIDs, acetaminophen (Tylenol®) may be worth trying. As an over-the-counter, non-NSAID pain reliever, acetaminophen can help ease aches, but is not as effective at combatting inflammation in the joints. While acetaminophen is safe at recommended doses, excessive doses are associated with an increased risk of liver toxicity, according to Cleveland Clinic rheumatologist Linda Mileti, MD.

“Since many medications contain acetaminophen, it is important to look at the labels of all medications you are taking to ensure you do not consume more than 3,000 milligrams per day,” she says.

Additional oral prescription options approved for pain management include antidepressant or anticonvulsant medications. “When patients have chronic pain it affects the pain threshold of the nerves sending signals to the brain,” explains Dr. ​Mileti. “Antidepressants and anticonvulsants work at the central nervous system level. They affect levels of serotonin and norepinephrine, which help modulate pain perception.”

The effect of an antidepressant medication builds slowly over time, and it may take several weeks to see the pain-relieving effects. With these medications you may experience mood changes, sexual side effects, nausea, increased heart rate, weight gain or loss, and fatigue. “The general rule of thumb for these medications is to start with a low dose and increase as needed or tolerated,” says Dr. Mileti.

Rub on relief

Topical medications in the form of gels, creams and patches can be applied directly to the skin over a sore joint to avoid exposing yourself to the GI risks of NSAIDs. One of the more popular and effective NSAID-containing gels is diclofenac (Voltaren® Gel). Diclofenac is the first prescription topical treatment for osteoarthritis (OA) approved by the Food and Drug Administration (FDA). In studies that led to the gel’s approval, pain levels fell by 46 percent among people with hand OA after they applied diclofenac for six weeks. In a 12-week study of people with knee OA, there was a 51-percent reduction in pain.

 Diclofenac is generally considered safe for patients who can’t take oral NSAIDs. “I find it useful on the hands, knees and elbows,” states Dr. Mileti. “Because it is an NSAID, it carries all of the same labeling risk factors, but I find that patients generally don’t have any problems and the GI side effects are minimized.”

Lidoderm® (lidocaine) patches are an additional effective alternative for providing pain relief. The active ingredient is an anesthetic, so it works as a numbing agent, and the patches can be applied once a day for up to 12 hours. Other topical agents available over-the-counter, such as IcyHot®, Salonpas® or Bengay®, consist of active ingredients including menthol, camphor, capsaicin, methyl salicylate, or some combination of these.

“Basically, these topical agents trick the body and mind by causing pain in one area to relieve pain in another area,” explains Mandy Leonard, PharmD, BCPS, system director of drug use policy and formulary management with Cleveland Clinic’s Department of Pharmacy.

Cautionary approach

While you may find pain relief with topical pain relief medications, it’s important to use them appropriately. “It is recommended that heating pads not be used with these products,” cautions Dr. Leonard.

“Any time you apply anything to the skin and apply an occlusive bandage or any type of heat, you increase blood flow to that area and increase absorption of that compound into the systemic circulation. Depending on the agent selected and the amount used, this could result in serious problems,” she explains. “With products containing methyl salicylate, you may experience symptoms of salicylate toxicity, which may begin with hyperventilation, or nausea and vomiting and can progress to very serious symptoms of confusion or seizures.”

Used correctly, topical medications can provide relief for a short time, but may not work well for long-term pain relief. Instead, injections of steroid or corticosteroid compounds offer the possibility of providing long-term pain relief. Depending on the individual, pain relief may lapse over time and require additional injections.

Outside the box

When thinking beyond the typical pain-relief approaches, many may consider transcutaneous electrical nerve stimulation (TENS) units. TENS are pocket-sized devices that provide pain relief through the electrical stimulation of nerve and muscle fibers. These units are available online and in stores, but do require some training to use properly.

“There is some controversy around the effectiveness of TENS units. Some studies show they are helpful; others show they are not,” states Dr. Mileti. “This might depend on the frequency of use, the strength of the electrical current used, or the length of time the unit is used. For the most part, they are generally safe. They are more helpful for chronic pain rather than acute pain.”

The physical stress of poor posture, lack of flexibility and deconditioned muscles due to arthritis can all lead to joint pain. Regular exercise can help and may lead to weight loss, which has many benefits and could potentially slow the progression of knee arthritis. A study appearing in the Annals of the Rheumatic Diseases (Jan. 2012) found that weight loss in patients with arthritis was associated with improvements in knee cartilage quality and thickness.

Proper footwear may also lessen pain in the leg joints. “There are some conditions in the feet that can predispose to worsening pain in the knees and the hips,” Dr. Mileti says. “When patients have an abnormality of the foot, I often send them to podiatry to find out if they need orthotics.”

Massage therapy can also be used for pain relief. “Massage can be helpful for chronic pain,” Dr. Mileti adds.

“Many people with chronic pain develop a lower pain threshold, which can lead to muscle spasms. Massage can be helpful to relieve those spasms, but does not address the arthritis in the joint,” she says.

Comments (10)

If you stop using gluten and also dairy products you will stop a hiatal hernia in no time also it will stop diverticulitis in no time but you can use oats 90% of the time .
I done so and it works for me .

Posted by: Martin12 | April 15, 2019 11:29 AM    Report this comment

Osteoarthritis is not easy to bare but saying that i am 74 and have found many good natural products .
I find turmeric with black pepper very good for inflammation taking for a long time also ginger . I also use devils claw boswellia and CBD oil. I go to the gym sauna and pool 3 times a week . I do not take any drugs because they make things much worse . Stay natural and try to enjoy , and exercise is the best pill

Posted by: Martin12 | April 15, 2019 11:20 AM    Report this comment

I have worked hard all my life and I am still very active at 73, but OA has slowed me down about 50%. Just a few days ago I had a GI Bleed. I spent 3 days in the hospital, with IV's and strong antibiotics treatments. When my GI doctor finally showed up, on day 3, he said no more NSAID's or aspirin.
I had my right knee replacement in May but, I would think long and hard before I do it again.
I wonder what I can take to easy the OA in my hands. Topicals only mask the pain and not effective after 1 hour.
For my back, I use infrared heat, and that works very well. I was surprised after two weeks using the IFR heat my lower back pain reduced by 70%. IFR penetrated to 2.36 inches whereas the cheap pads only penetrate 1 to 2 millimeters. The IFR heating pad is expensive, about $239 for good quality, but well worth it.

Posted by: SkyHigh | January 30, 2019 9:07 AM    Report this comment

I have had OA in my knees for 31 years (and everywhere else for about 20 years), and until about 10 years ago, I could take NSAIDs for the pain. I developed an intestinal bleed, and I can no longer take them (aside from the fact they make me roll with pain now). I was taking magnesium supplements, which helped, but the supplements gave me diarrhea, so I had to stop those. I discovered topical magnesium spray, and for me, it works wonders. It doesn't always take away ALL the pain, but I think that's a bit much to expect after all these years. If I run out of the spray (I have to order it) I use CBD oil. Not only does this relax the muscles around the arthritic joints, it helps the bone pain.

Posted by: terdralynn | August 1, 2018 1:02 PM    Report this comment

Hi .im new to this forum . I have psoriatic arthiritis , chronic kidney disease and possibly Gurd or ulcer . I have managed with steroid I m injections for pain and flare ups till now , I'm probably starting methotrexate January .
I'm really struggling with pain relief , I can't do anti inflams due to ckd , I've used co codamol but it's recentlt started upsetting my tummy at the top . Paracetamol is to mild sometimes . I do have brufen gel 10% , but sometimes the pain is in so many places , Has any one got any advice on pain relief. I'm uk based . Debbie

Posted by: Debbi793 | October 25, 2017 12:43 PM    Report this comment

Mary Ann Smothermon... I have a hiatal hernia to, I've taken many different things for it and nothing has even come close to " ranitidine " I've been on it for many many years. I take 300. Mg twice a day. It's my miracle drug.

Posted by: Shara | September 6, 2017 2:28 PM    Report this comment

I take dilaudin, a narcotic, i don't care. And soma for muscle spasms. I can't take nsaids for stomach problems. What else is there to do? I exercise and do everything else I can do, but I will take a narcotic before I live in pain!

Posted by: Shirley lewis | May 30, 2017 3:32 PM    Report this comment

This is cynically hilarious. Don't take NSAIDs because of this that and the other. But don't use rub on relief because that causes a different problem. And TENs units are "controversial."

It is utterly mind-boggling that all the medical community can offer us is prescription drugs, all with side effects (which they then treat with more prescription drugs), and dire warnings of what over the counter alternatives can do to your body. With millions of people in chronic pain, it is flirting with negligence to not utilize your precious R&D money to figure out how to help us, without doing further damage to our bodies. I guess that's why it's called a "medical practice," because y'all really don't know.

Posted by: CynthiaC | May 29, 2017 9:44 AM    Report this comment

It is absolutely mind-boggling that all the medical community can do is create a dependency on prescription drugs (all with side effects that doctors treat with more prescription drugs), yet they cannot develop an over the counter pain reliever that does't cause serious side effects. With millions of people in some form of chronic pain, it is interesting how many doctors turn a blind eye to their patients suffering, offering them only drug dependency and dire warnings.

Posted by: CynthiaC | May 29, 2017 9:39 AM    Report this comment

I HAVE SEVERE GURD AND JUST CHANGED FROM PROTONIX 40MG TO NEXIUM 40 MG TIMES TWICE DAILY. I HAVE HISTORY OF STOMACH ULCERS,I ALSO HAVE IBS/D
I SUFFER FROM ISCHEMIC COLITIS. HIATIAL HERNIA . HAVE HAD POLYPS ON COLON SEVERAL TIMES AND REMOVED .
I AM NOT ABLE TO TAKE MEDICATIONS FOR MY SEVERE OSTEO AND FIBRO,CHRONIC FATIGUE ,SO I HAVE BEEN TAKING METHOTREXATE INJECTIONS AT HOME FOR OVER A YEAR. 6LM ONCE WEEKLY.
IM HAVING MINI DENTAL IMPLANT TOMORROW STARTS PROCEDURE. STOPPED MTX TWO WEEKS BEFORE AND AFTER. CAN NOT TAKE ANTI- INFLAMMATORY
SO, IS THERE ANYTHING I CAN TAKE THAT WONT HURT ALL MY OTHER ISSUES FOR THESE IMPLANTS? I'M IN DESPERATE NEED OF SOMETHING ,PLEASE RESPOND ASAP. I AM A 64 YR OLD WOMAN IN FAIR HEALTH.THANK YOU

Posted by: Mary Ann Smothermon | May 2, 2017 2:24 PM    Report this comment

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